Responsibility for buying around £60bn of healthcare services, mainly from hospitals, will is moving from primary care trusts to local clinical commissioning groups. Photograph: David Sillitoe for the Guardian

As the reforms enshrined in the Health and Social Care Act take shape, no one knows where the power lies, who will lead the system or whether the weakest trusts will be left to the predations of the market.

From next April responsibility for buying around £60bn of healthcare services, mainly from hospitals, will move from primary care trusts to local clinical commissioning groups (CCGs) led by GPs. Nationally, the new NHS Commissioning Board will set standards, hold the commissioning groups to account and implement policy priorities laid down by the government.

As money for providers gets tighter, services will need to be "reconfigured" to produce savings, such as by moving specialist services to regional centres. But will changes be planned, or will they be triggered by a weak trust getting into financial difficulties?

Mike Farrar, chief executive of the NHS Confederation, the umbrella group for health service organisations, says: "The risk is that if you take the second strategy, as providers get closer to the edge they could take shortcuts with quality and safety. We need to be more proactively planning change [rather] than allow change to happen on the basis of failure."

But who will do the planning? Part of the job of CCGs is to move care from hospitals to the community. That may well benefit an individual patient but the CCGs will find it difficult to judge the cumulative impact on the viability of a hospital service or trust.

"Unless you are going to say it is all driven by a free market … then maybe the new system has to invent a new form of system management," Farrar says.

Chris Ham, chief executive of the health thinktank The King's Fund, believes CCGs will struggle to lead on strategic issues: "Given all that CCGs have on their plate, I think it is a big ask to expect them to step into that vacuum."

He hopes that in the short term, primary care trusts and strategic health authorities will use their last few months to lay foundations for some long overdue service reconfigurations, while in the longer term he foresees a continuing role for the NHS Commissioning Board.

David Bennett, chair of NHS regulator Monitor, says the absence of a "strategic brain" means changes will have to be agreed through "multilateral discussions".

But that is risky for the NHS. Major service changes are already difficult to sell to the public; local organisations fighting it out will only further undermine confidence that patients' interests are at the heart of decisions.

Bennett says the extent to which foundation trusts will compete by opening new services or expanding into new localities will depend on how much appetite they see from CCGs to change the way services are delivered.

The NHS Commissioning Board's duty to ensure each CCG is ready to operate could put it at odds with ambitious GPs anxious to start leading their local NHS without central interference. But Clare Gerada, chair of the Royal College of GPs, stresses the importance of letting the system bed down rather than taking risks with "vast amounts of public money".

When it comes to resisting the controlling instincts of the commissioning board, local health and wellbeing boards will be pushing CCGs to keep a local focus. Steve Field, GP and chair of the advisory NHS Future Forum, believes this democratic accountability will make a pivotal difference, arguing the health and wellbeing boards "are absolutely the key organisation".

Improving primary care

But one perverse outcome of the reforms is that the most local part of the NHS – primary care – is now the responsibility of the commissioning board. Stephen Thornton, chief executive of the Health Foundation, fears focus on "the urgent priority of improving primary care will be lost. Some of it is awful."

Just as the NHS begins to get to grips with the reforms, there is the risk of another convulsion once the report by Robert Francis QC into the Mid Staffordshire Foundation Trust scandal is published this autumn. The inquiry has examined the role of the commissioning, supervisory and regulatory bodies in the monitoring of the Mid Staffordshire Foundation Trust, which follows an earlier report that looked into standards of care at the trust.

Farrar fears a "knee jerk reaction which leads to greater and greater emphasis on regulation and inspection". He says investing time and energy in staff will deliver high-quality care, regulation will not. "Our message around Francis is you need a balance between organisational regulation and the support that individuals need to provide the best care. If you look at the work done by the Commission on Improving Dignity in Care for Older People, you see that high-quality care is about valuing your frontline staff who then go the extra mile."

While the reforms and Francis will dominate political debate, there is an increasing consensus in the NHS that culture change is more important than rules and structures. As Ham says: "If the culture does not change in the next five years all the fuss around the reforms will not have been worth one iota. The NHS needs to put the patients at the centre of care and clinicians much more in control of how the service runs."

Thornton agrees: "It is empowering the patient and their carers and getting a more equal relationship [between patients and staff] that is ultimately going to make the big difference."

Ham is sceptical about expecting the NHS to improve service quality as well as cut costs and implement the reforms. "The job between now and 2014 is to get through this high-risk transition period and navigate the treacherous waters ahead," he says. The reforms have always been very high-risk and the NHS will have done a fantastic job if it keeps control of money, keeps control of performance on the key indicators, makes all of these organisational changes and puts CCGs in place to do all the thing we hope they will do."

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